Title of Presentation

Report
Cal MediConnect
Martha Smith
Chief Program Officer, Dual Eligible Demonstration
Health Net, Inc.
Paul Van Duine
Senior Director of Provider Network Operations
L.A. Care Health Plan
CAPG Southern California Contracts Committee Meeting
Annual joint meeting with HASC
October 3, 2013
1
Agenda
Background and General Update
LA Care Network Strategy
Coordinating Behavioral Health
Health Net Network Strategy
2
California is implementing a Duals Demonstration
under the Coordinated Care Initiative
The passing of the Coordinated Care Initiative (CCI) is a
catalyst for three key changes in California healthcare in the 8
selected counties:
Mandatory enrollment into a
Medi-Cal health plan
California
CCI
Legislation
Mandatory transition of Medi-Cal
Long Term Services and Supports
(LTSS) to Medi-Cal health plans
Voluntary transition of Dual Eligibles
into a Demonstration plan (passive, with
opt-out)
3
As a result of CCI, what changes for Medi-Cal Benes?
• Most Medi-Cal beneficiaries will have to join a Medi-Cal health plan for
benefits like:
o
o
o
o
Long Term Services and Supports (LTSS)
Non-emergency transportation (medically necessary)
Incontinence supplies
Some medical equipment that Medicare doesn’t cover.
• Dually Eligible beneficiaries can join the Duals Demonstration and get
ALL of their healthcare from one health plan (Medicare and Medi-Cal
benefits)
• Dually Eligible beneficiaries can opt out of joining a health plan for the
Medicare portion of their services. They will have to remain in a health
plan for their Medi-Cal services
4
California Demonstration Sites
•
Eight counties have been selected
based on current State authority*:
o Los Angeles (DE pop. 374 K, eligible: 271K)


o San




Health Net
LA Care
Diego (DE pop. 75 K eligible: 51K)
Health Net
Molina
Care 1st
Community Health Group
o Orange (DE pop. 73 K eligible: 57K):

CalOptima
o San Bernardino (DE Pop. 54 K eligible: 36K)


Inland Empire Health Plan
Molina Healthcare
o Riverside (DE Pop. 50 K eligible: 34K)


o
o
o
Inland Empire Health Plan
Molina Healthcare
Santa Clara (DE Pop. 50 K eligible: 35K)
 Anthem Blue Cross
 Santa Clara Family Health Plan
Alameda (DE Pop. 42 K eligible: 31K)
 Anthem Blue Cross
 Alameda Alliance for Health
San Mateo (DE pop. 15 K eligible: 11K)
 Health Plan of San Mateo
5
What will the Program Look Like?
Benefit Plan Configuration
Medicare:
• Parts A, B, and D benefits covered
Medi-Cal:
• All Medi-Cal services currently
required in managed care services
• Long-Term Supports and Services
o Skilled Nursing
o Home and Community-Based
programs
Supplemental benefits:
• Vision, Transportation
• (optional dental)
Coordination:
• With mental health and substance
use programs
• Other “non-benefit” community
based programs
6
What will the Program Look Like?
Who and How?
Who Will Be Included in Cal MediConnect?
•
Beneficiaries eligible for both full benefit Medicare and Medi-Cal in the CCI
counties
Populations excluded from the Demo
•
•
•
•
•
•
•
Partial-Benefit Dual Eligibles
Beneficiaries with other health coverage (not including Medicare Advantage or
partial coverage plans)
Beneficiaries under age 21
Existing ESRDs (enrollment will be consistent with MA today)
Beneficiaries with developmental disabilities receiving services through
Regional Centers or a State Developmental Center
Enrollees of selected waiver programs
Beneficiaries living in zip codes not covered by managed care
7
What will the Program Look Like?
Timing
•
The Demonstration will begin no sooner than April 1, 2014
•
Enrollment
o Enrollment for the eight counties in the CCI will have different approaches
 Los Angeles  enrollment will phase in over 12 months with the first three
months being a period of only active choice enrollment
– Active/elective enrollment April – June 2014
– Passive enrollment by birth month beginning July 2014 – March 2015
– 200,000 enrollment cap
 San Diego  enrollment will phase in over 12 months by birth month beginning
April 2014
 San Mateo and Orange  commence all at once on April 2014
o Passive enrollment with a voluntary opt out for the Medicare benefit only
 Beneficiaries can opt out of Cal MediConnect
 If beneficiaries don’t choose to opt out or select a health plan, they will be
automatically enrolled by the State into either L.A. Care or Health Net
o Current D-SNP and MA enrollees are passively enrolled in January 2014
o Beneficiaries can still opt out later even if they get automatically enrolled
•
Financing:
– Capitated payment models with 3-way contracts between CMS, CA Department of
Health Care Services (DHCS), and health plans
8
Coordinated Care Initiative Requirements
The legislation establishing the CCI contains many projections
for beneficiaries covering:
• Meaningful Information of Beneficiary Rights and Choices:
o Notices sent at least 90, 60, and 30 days prior to enrollment
(coordinated with CMS)
•
Continuity of Care
o People can continue to see their Medi-Cal providers for 12 months and
Medicare doctors for 6 months
•
Self-Directed Care:
o People will have the choice to self-direct their care, including being able
to hire, fire, and manage their IHSS workers
•
Appeals & Grievances:
o
•
DHCS is working with CMS on a coordinated appeals process
Strong Oversight & Monitoring:
o
Evaluation Coordinated with DHCS and CMS
9

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